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5 <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH, DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE- (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201. <br /> pERMTT EXPIRES 1 YEAR FROM DATE 10SUED <br /> (Complete in Triplicate) <br /> Application is hereby made,to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. y�f A C <br /> 40�Job Address <br /> .r W� /�l a /� City Lot Size/Acreage Z <br /> Owner's Name <br /> G(iC/ Address 9�4 of Phone <br /> 4!T f��a�r Address 17F License No377. <br /> Contfactor ?d1' Phoneme y�J� <br /> TYPE OF WELL/PUMP, NEW WELL WELL REPLACEMENT ❑ DESTRUCTION 0 Out of Service Well ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR El OTHER Monitoring Well ,❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> TENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> du trial ❑ Open Bottom ❑ Manteca Dia. of Well Excavatio Dia. of Well Casing 'C <br /> t Type of Casing vG Specifications <br /> Do estic/Private } Gravel Pack n Tracy <br /> ublie fa Other L1 Delta Depth of Grout Se l Z- Type of Grout a <br /> i I Irrigation 3 ��.Approx. Depth l I Eastern Surface Seal Instal d by w Ate'~� <br /> Repair Work Done U Type of Pump — <br /> H.P. State Work Done A23A <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> i <br /> Depth bFiller Material Depth <br /> th 5 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I i OESTRUCTION;1 I INo sbetic sy t m rented if public sewer is <br /> installation will serve: Residence_ Commercial— Other �! o <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTiG TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. Cl t Method of Disposal <br /> I Distance to nearest: Well Foundation Property Line <br /> 1 <br /> LEACHING LINE Cl No. & Length of lines Total length/size <br /> FILTER BED Cl Distance to nearest: r Well Foundation Property Line <br /> f r <br /> �^ <br /> SEEPAGE PITS l I Depth Size Number ` <br /> -SUMPS CI Distance to nearest: Well Foundation } Property Line ` <br /> i r <br /> ',.DISPOSAL PONDS Q <br /> 'I-hereby certify that I have prepared this application and that the work will be done in accordance with SanJoaquincounty ordinances, state laws, and <br /> lutes and regulations of the San Joaquin County / <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ-any-person in such manner as to become-subject-to.work man's compensationlaws of California."Coritractor's hiring or sub-contracting signature <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." ` " ' `1A <br /> The applicant must tali for all required inspections. Complete drawing on reverse side, ;, f <br /> Signed X- Title: _ Date: <br /> OR�f'SEPARTfWE1VT USE ONLY <br /> Application Accepted by Date <br /> Pit or ro Inspection by + Date� Final Inspection by ! '\ 1. � _ �..•Date `C <br /> Additional Comments: - f <br /> l • <br /> Applicant - Return ell copies to: San Joaquin County Public Health <br /> + Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> CK 0 FEE. -AMOUNT DUE AMOUNT REMITTED CASH <br /> RECEIVED-BY---- DATE PERMIT N0. <br /> INFO <br /> a EH 13-24[REV.I/"51 ;�`-' t • q. <br /> sit. <br /> EH;4-26 <br />